Clinical Appeals Coordinator

Oklahoma Complete Health; Arkansas; Remote; USD 60,000 - 80,000; Full time

Job summary

A leading healthcare organization is seeking a Clinical Appeals Coordinator to manage statewide appeals and ensure compliance with regulations. The role requires an RN or LPN/LVN with significant clinical experience. The position offers a competitive pay range and a comprehensive benefits package, including health insurance and flexible work options.

Benefits

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

Qualifications

• RN with 4+ years of clinical nursing or case management experience.
• LPN/LVN with 5+ years of clinical nursing or case management experience.
• Managed care or utilization review experience preferred.

Responsibilities

• Act as the liaison for all statewide appeals and ensure compliance with State and NCQA requirements.
• Review clinical information for appeals and prepare response letters.
• Coordinate Fair Hearings with various internal departments.

Skills

Clinical nursing

Case management

Analysis

Education

RN license

LPN/LVN license

Job description

Clinical Appeals Coordinator page is loaded

Clinical Appeals Coordinator

Apply locations: Remote-AR, Remote-KS
Time type: Full time
Posted on: Posted 2 Days Ago
Job requisition id: 1564296

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.

Position Purpose:

Act as the liaison for all statewide appeals, fair hearings, review organizations, and other external appeals. Responsible for ensuring that all appeal letters generated comply with both State and NCQA requirements.

• Review clinical information for all appeals utilizing nationally recognized criteria to determine the medical necessity of services requested. Prepare reviews for cases that did not meet criteria.
• Gather, analyze, and report verbal and written information regarding member and provider clinical appeals, including follow-up information.
• Prepare response letters for member and provider clinical appeals and ensure letters are compliant with State and NCQA standards.
• Maintain files and logs for all appeals.
• Coordinate with Medical Director(s) to clarify medical determinations or clinical rationale.
• Maintain current knowledge of NCQA and State regulations.
• Coordinate Fair Hearings with various internal departments and agencies.

Education/Experience:

RN with 4+ years of clinical nursing and/or case management experience or LPN/LVN with 5+ years of clinical nursing or case management experience. Managed care or utilization review experience preferred.

License/Certification:

LPN, LVN, or RN license.

Corporate & Louisiana Healthcare Connections Requirements:

Current state RN, LPN, or LVN, LPC, LCSW, or Psy.D license.

Pay Range: $33.03 - $59.47 per hour

Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law. Total compensation may also include additional forms of incentives.

Centene is an equal opportunity employer committed to diversity. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by law.

Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act.